Self-Trust and Reproductive Autonomy

There is a long tradition of feminist critique of reproductive technologies and the concept of autonomy.  Carolyn McLeod’s book, Self-Trust and Reproductive Autonomy, builds on this tradition.  Her unique and valuable contributions stem from an enriched understanding of autonomy within a relational social context.   She skillfully uses narratives of women with miscarriages, assisted reproductive technologies, and prenatal screening to demonstrate the importance of self-trust for autonomous decision-making.  Ultimately, she makes recommendations for how health care professionals can improve their patient’s self-trust and autonomy.

Her book is clearly written and well organized.  With only a few exceptions, the reader can easily follow her arguments.   Each chapter flows logically into the next.  She begins by arguing for the existence of “self-trust.”  Demonstrating a good knowledge of the philosophic and psychological literature on trust, her arguments were fair and sufficient to support the existence of such a concept.  She successfully distinguishes it from self- confidence and self respect by defining self-trust as an emotion of optimism that one will act consistent with one’s own moral integrity.

McLeod’s version of self-trust opens it up to many of the benefits and risks of traditional trust.  Self-trust makes us vulnerable to the risk that our optimism is unfounded.  Self-trust is vulnerable to external input from individuals and society.  This point is one of the most valuable contributions of this book.  McLeod’s chapters on vulnerability and the epistemic nature of self-trust demonstrate the various ways that oppression and discrimination can affect the degree of self-trust that one has.  For example, the judgment of whether self-trust is reliable is made in part by comparing it to external, as well as internal cues.  If the responses from others consistently conflict with one’s own value judgments, then one may assume that one’s own judgment is wrong.  Oppressive messages from others and society can cause one to adopt a mistaken view of one’s values, as well as the degree of self-trust that is warranted. 

McLeod builds on this in her discussion of autonomy.  When a person’s degree of self-trust or distrust is warranted, it supports autonomy.  Similarly, when either is inaccurate (too much or too little) then autonomy suffers.  But McLeod points out that the relationship is more complicated than it seems.   Consider an example of a woman who distrusts herself to make complicated medical decisions because her social feedback in this situation has consistently told her that uneducated women are not capable of making such decisions.  In such a situation, McLeod says that the woman’s distrust of her decisional capacity may be well grounded if it accurately reflects her current abilities.  However the distrust is also unjustified because the input from the oppressive environment is inaccurate.  This is an important distinction because it demonstrates means for improving self-trust.  It also demonstrates the relational nature of autonomy.  McLeod does not conclude that those who are oppressed should not be treated as autonomous agents. Rather, she recommends that health care professionals point out inaccurate beliefs and help guide self-distrustful patients through the decisional process in a manner that promotes self-trust. 

The practical import of this analysis of self-trust and its social elements for enhancing patient autonomy is demonstrated by the use of cases throughout the book.  The final chapter focuses on the implications of her conclusions for medical practice.  McLeod’s recommendations focus on practical changes that health care professionals can take for improving the care of individual patients, while granting that greater benefits would come from changing the culture of medicine.  While she focuses on physicians, her recommendations are helpful for all health care professionals.

The book’s strengths are weakened only by the occasional appearance of McLeod’s own biases.  Most of the time she analyzes points fairly, addressing major counterarguments to her approach.  But, she occasionally lapses into overgeneralization.  The biggest example of this is how assisted reproductive technologies (ART) and pre-natal testing techniques are almost universally portrayed in this book as oppressive and harmful to women. This kind of bias leads to a few errors of reasoning.  The logic supporting the final conclusions stands despite these errors.  However, this bias may undermine communication of the book’s message to obstetricians and specialists in reproductive endocrinology and infertility.   This is a shame since the recommendations are directed towards them. 

With that last caveat, I highly recommend this text.  Its strengths outweigh its weaknesses.  It provides a valuable addition to the discussion of autonomy and informed consent.  Her elaboration of self-trust provides a way to acknowledge the real damage of oppression and trauma on a person’s psyche without undermining respect for his/her autonomy.  

© 2003 Constance Perry

Constance Perry, Ph.D. teaches courses in biomedical ethics and philosophy at Drexel University.  She serves on two clinical ethics committees and Drexel’s Institutional Animal Care and Use Committee.  Her research interests include autonomy, personhood, ethical issues in reproduction and pregnancy, and the ethics of animal experimentation.